Appetite 58 (2012) 847–851

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Appetite
journal homepage: www.elsevier.com/locate/appet

Research report

Dealing with problematic eating behaviour. The effects of a mindfulness-based

intervention on eating behaviour, food cravings, dichotomous thinking and
body image concern
H.J.E.M. Alberts ⇑, R. Thewissen, L. Raes
Maastricht University, Faculty of Psychology and Neuroscience, Clinical and Psychological Science, P.O. Box 616, 6200 MD Maastricht, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: This study explored the efficacy of a mindfulness-based intervention for problematic eating behavior. A
Received 27 September 2011 non-clinical sample of 26 women with disordered eating behavior was randomly assigned to an 8-week
Received in revised form 28 November 2011 MBCT-based eating intervention or a waiting list control group. Data were collected at baseline and after
Accepted 5 January 2012
8 weeks. Compared to controls, participants in the mindfulness intervention showed significantly greater
Available online 10 January 2012
decreases in food cravings, dichotomous thinking, body image concern, emotional eating and external
eating. These findings suggest that mindfulness practice can be an effective way to reduce factors that
Keywords:
are associated with problematic eating behaviour.
Mindfulness
Food craving
Ó 2012 Elsevier Ltd. All rights reserved.
Dichotomous thinking
Body dissatisfaction
External eating

Introduction Eating behaviour

Mindfulness is the practice of focusing attention on the expe-
rience in the present moment in an accepting manner, without
judgment or attachment to the way this experience should or
should not be (Kabat-Zinn, 1990). Today, only a relatively small
number of studies have addressed the effectiveness of mindful-
ness in the domain of eating behavior. So far, the findings are
promising and suggest an inverse relationship between mindful-
ness and disordered eating behavior. Mindfulness practice has
been found to reduce BMI in overweight individuals (Tapper
et al., 2009), decrease food cravings (Alberts, Mulkens, Smeets,
& Thewissen, 2010) and reduce binge eating (Kristeller & Hallett,
1999). Moreover, high levels of mindfulness have been found to
be negatively associated with disordered eating-related cogni-
tions (Masuda & Wendell, 2010). The goal of the present study
was to extend this line of research and address the efficacy of a
mindfulness-based intervention on different important correlates
of disordered eating behavior. More specifically, we explored the
impact of an 8 week mindfulness-based intervention on BMI,
eating behavior, food cravings, dichotomous thinking and body
image concern.
⇑ Corresponding author.
E-mail address: h.alberts@maastrichtuniversity.nl (H.J.E.M. Alberts).
Three dissimilar styles of eating behavior have been identified:
restrained, emotional and external eating (Van Strien, Frijters,
Bergers, & Defares, 1986). Restrained eating involves restriction
of food intake or dieting. Dieting has been found to play a role
in the development of eating disorders (Stice, 1998) and pro-
motes unhealthy cycles of weight loss and gain (Lissner, Andres,
Muller, & Shimokata, 1990). Restrained eating can be driven by
appearance related evaluative processes and cognitions, such as
judgment of the self in terms of shape and weight (Spangler,
2002). Mindfulness cultivates acceptance and aims to reduce
the impact of (self-related) judgmental processes by enhancing
dis-identification from these judgments. Consequently, mindful-
ness is likely to reduce restrained eating that is driven by
negative self-evaluative processes.
External eating is eating in response to external cues, not
considering internal states of hunger and satiety. Individuals who
often engage in external eating are more likely to snack in stressful
situations (Conner, Fitter, & Fletcher, 1999) and have feelings of
low self-worth (Braet & Van Strien, 1997). To a large extent, mind-
fulness based practice includes exercises, such as the bodyscan,
that direct attention inward, to the experience of thoughts, feelings
and body related sensations (Kristeller & Hallett, 1999). In this
way, attention for internal cues is strengthened, which may atten-
uate guidance of (eating) behaviour by external cues and thus
reduce external eating.

0195-6663/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.appet.2012.01.009
848 H.J.E.M. Alberts et al. / Appetite 58 (2012) 847–851
Emotional eating has been defined as eating in response to neg-
ative emotions (Van Strien et al., 1986) and has been identified as
an essential aspect of binge eating (e.g., Arnow, Kenardy, & Agras,
1995). Whereas emotional eating can be perceived as an escape
from experiencing negative emotions (avoidance coping; Cochra-
ne, Brewerton, Wilson, & Hodges, 1992), mindfulness promotes
willingness to approach and experience emotions, and is therefore
likely to reduce avoidance based coping, such as emotional eating.
Body image concern
A negative perception of one’s physical appearance (body im-
age; Fisher, 1990) has been identified as an important factor con-
tributing to vulnerability to, and maintenance of disordered
eating behaviour (Cooley & Toray, 2001). Factors that have been
suggested to contribute to the development and maintenance of
body dissatisfaction include appearance ideals (Thompson, Hein-
berg, Altabe, & Tantleff Dunn, 1999), body checking and body
avoidance (Shafran, Fairburn, Robinson, & Lask, 2004). Placing high
value on appearance ideals, such as the thin body ideal, can raise
body dissatisfaction by increasing the awareness of the discrep-
ancy between one’s current and ideal body. Body avoidance in-
volves behavior that aims to prevent or avoid situations that
trigger concern about one’s physical appearance. Examples are
wearing baggy clothes, not weighing or avoiding mirrors. Body
avoidance may prevent disconfirmation of irrational ideas about
one’s body (Rosen, Srebnik, Saltzberg, & Wendt, 1991). In contrast,
body checking refers to a critical examination of one’s body, like for
instance checking oneself repeatedly in the mirror or negatively
comparing oneself to others.
Mindfulness is in sharp contrast with the above described pro-
cesses and behavior that are proposed to increase and maintain
body image concern. First, mindfulness is not primarily focused
on reaching a goal or ideal state, but fosters willingness to accept
the present state. In other words, instead of attempting to reach
an appearance ideal, mindfulness promotes acceptance of the cur-
rent appearance, despite social pressures to do otherwise. Second,
mindfulness draws on the ability to stay in contact with an expe-
rience. Thus, in contrast to body avoidance, mindfulness requires
willingness to expose oneself to whatever arises. Importantly,
mindfulness cultivates compassion and attention without judg-
ment. This is opposite to the principle of body checking, which is
a strongly judgmental and self-critical evaluative process. Follow-
ing this line of reasoning, increased levels of mindfulness are ex-
pected to be associated with less body image concern.
Dichotomous thinking
Dichotomous thinking entails a type of cognitive rigidity in
which reality is perceived in terms of polarities (e.g. food is either
‘‘good’’ or ‘‘bad’’). This thinking style has been identified as an
important factor contributing to the maintenance of eating disor-
ders (Fairburn, Cooper, & Shafran, 2003). Dichotomous thinking en-
hances obsessive processing by stimulating feelings of guilt after
consumption of ‘‘forbidden’’ food (Dewberry & Ussher, 2001) and
by increasing the attractiveness of forbidden food (Mann & Ward,
2001).
A core component of mindfulness is non-judgmental observa-
tion of internal and external stimuli. Instead of labeling reality in
dichotomous terms such as ‘‘good’’ or ‘‘bad’’, mindfulness promotes
willingness to accept and let things be just as they are the moment
we become aware of them. Mindfulness practice can help to in-
crease awareness of critical and judgmental thoughts, without get-
ting involved in these thoughts. This process of dis-identification
allows one to gain distance from evaluative thoughts and is there-
fore likely to decrease dichotomous thinking.
Food cravings
Food cravings are defined as an intense desire or urge to eat
specific food (Weingarten & Elston, 1991). Positive correlations
have been observed between food cravings and the development
of obesity (Schlundt, Virts, Sbrocco, & Pope-Cordle, 1993) and eat-
ing disorders (Mitchell, Hatsukami, Eckert, & Pyle, 1985). Recent
findings suggest that mindfulness-based coping is effective in
reducing cravings. In a study by Alberts et al. (2010) it was found
that overweight and obese participants who received a 7-week
mindfulness-based intervention reported significant reductions in
food cravings compared to control participants. Although prelimin-
ary, these findings imply that mindfulness can help to reduce crav-
ing for food.
Method
Participants
Patients were recruited through a newspaper advertisement
and flyers soliciting for individuals with problematic eating behav-
ior. The inclusion criterions were that participants were (1) be-
tween 18 and 65 years and (2) experienced one or more of the
following types of problematic eating: emotional eating, stress
related eating, eating without awareness and/or overeating. Exclu-
sion criteria were: (1) eating disorder (bulimia nervosa or anorexia
nervosa), (2) suicidality, (3) substance abuse and/or dependence,
(4) severe mental disorder, and (5) other concurrent treatment. A
total of 26 women (mean age = 48.5 years, SD = 7.90), participated
in this study. The mean weight of the participants was 94.6 kg
(SD = 16.41; range 68.0–123.0) and the mean body mass index
(BMI) was 32.7 (SD = 6.1; range 23.5–45.8).
Design
After diagnostic evaluation and intake assessment, participants
were randomly assigned to the treatment group (n = 12) or wait-
ing-list control group (n = 14). The waiting-list period lasted for
the duration of the treatment period (8 weeks), and the control
group entered active treatment after 10 weeks. Measures for both
groups were collected at baseline and at post-treatment.
Measures
Weight
Weight (kg) was recorded at pre- and post-test. Participants
were weighed in street clothes, without shoes.
Kentucky Inventory Mindfulness Skills Extended (KIMS-E)
In order to test whether the current intervention successfully
increased levels of mindfulness, the KIMS-E (Baer, Smith, & Allen,
2004) was administered. This is a 46-item scale that measures
mindfulness skills or sub skills. The scale consists of five subscales;
observe, describe, act with awareness, act without judgement and
non-reactivity to inner experience (Crohnbach’s alpha = .94).
Dutch Eating Behaviour Questionnaire (DEB-Q)
The DEB-Q (Van Strien et al., 1986) consists of 33 items and
assesses external, restraint and emotional eating (Cronbach’s
alpha = .85).
Body Shape Questionnaire (BSQ)
The BSQ was originally developed by Cooper, Taylor, Cooper,
and Fairburn (1987) to measure concern about body weight and
shape experienced by individuals with eating disorders or related
 H.J.E.M. Alberts et al. / Appetite 58 (2012) 847–851
body image problems. We used the shortened 16 item version
(Evans & Dolan, 1993) (Cronbach’s alpha = .91).
The Dichotomous Thinking Scale (DTS)
The DTS (Byrne, Cooper, & Fairburn, 2004) is a 16-item scale
that measures the extent to which individuals engage in dichoto-
mous thinking. The scale consists of two sections; six items relate
specifically to food, dieting and weight, and 10 items concern more
general forms of dichotomous thinking (Cronbach’s alpha = .90).
General Food Craving Questionnaire Trait (G-FCQ-T)
The G-FCQ-T is a reliable and valid 21-item self-report measure
of a general ‘desire for food’ or ‘desire to eat’ (Nijs, Franken, &
Muris, 2007) consisting of the following four subscales (1) preoccu-
pation with food, (2) loss of control, (3) positive outcome expec-
tancy, and (4) emotional craving (Cronbach’s alpha = .94).
Participation check
After the intervention, participants in the experimental condi-
tion were asked to indicate how much time on average they spent
per day on the exercises. In addition, session attendance was reg-
istered by the trainer.
Procedure
All participants completed the questionnaires before onset of
the intervention period and directly after the intervention period
at home using a website. They were told that the completion of
the questionnaires would be anonymous. For participants in the
treatment condition, height and weight (kg) were recorded at the
beginning of the first session and at the beginning of the last ses-
sion. Weight of participants in the control condition was measured
at the same time intervals as the treatment condition, but at a dif-
ferent location.
Treatment
A specially designed mindfulness-based eating program was
delivered by the second author based on the MBCT protocol
developed by Segal, Williams, and Teasdale (2002). While largely
maintaining the overall structure and practices of the original
MBCT-protocol, some adjustments were made in order to increase
it’s relevance for eating behavior. The intervention consisted of five
core components: (1) mindful eating (awareness of sensations such
as taste), (2) awareness of physical sensations (hunger, satiety,
craving and stress), (3) awareness of thoughts and feelings related
to eating (e.g., inner self-talk, beliefs, judgments, expectations,
(diet)-rules, fear, sadness, shame and guilt), (4) acceptance and
non-judgment of sensations, thoughts, feelings and body, (5)
awareness and step-by-step change of daily patterns and habits
of eating and physical activity. The intervention consisted of
8 weekly sessions of 2.5 h. Exercises and skills being taught in-
cluded the bodyscan, sitting and walking meditation, mindful
eating skills, acceptance of oneself and one’s body, and dealing with
the paradox of control. Participants were invited to practice these
exercises at home for approximately 45–60 min a day.
Results
Participation check
There were no drop-outs in the experimental condition. Of the
12 people in the treatment group, five failed to attend one meeting,
two failed to attend two meetings and one person missed three
849
meetings. On average, participants indicated that they spend
29.38 min (SD = 17.41; range 10–60) per day on the exercises.
Analyses
All of the following analyses were performed using repeated-
measures ANOVA with measurement time as a within subjects fac-
tor (two levels; pre-test and post-test) and condition as a between
subjects factor. In order to address within group comparisons,
paired samples t-tests were employed. All means are summarized
in Table 1.
BMI
For BMI, only a significant main effect of measurement time
emerged, F(1, 24) = 8.65, p < .01, g2 = .27, indicating a decrease of
BMI at post-test, in general. Within group comparisons showed a
significant reduction in BMI for participants in the control condi-
tion, t(13) = 2.22, p < .05, d = .04 and a marginally significant de-
crease for those in the experimental condition, t(12) = 2.0, p = .07,
d = .06.
Mindfulness
Scores on the KIMS-E were found to significantly interact with
condition, F(1, 24) = 4.90, p = .04, g2 = .17. Participants in the con-
trol condition reported a non-significant increase in mindfulness,
t(13) = 1.93, p = .08, d = .19, while individuals who participated in
the training reported a significant increase in mindfulness,
t(12) = 3.31, p < .01, d = 1.15.
Eating behaviour
Restrained eating
Only a marginally significant main effect was observed for the
restrained eating subscale of the DEB-Q, F(1, 24) = 3.80, p = .06,
g2 = .14, suggesting that both the experimental and control group
reported an increase in restrained eating. No significant interaction
effect for this subscale was found, F(1, 24) = .21, p = .65.
External eating
For the external eating subscale, a significant interaction effect
was found, F(1, 24) = 4.80, p = .04, g2 = .17. Within group compari-
sons revealed no significant difference in external eating score
between the pre- and post-measurement of the control group,
t(13) < .001. In contrast, participants in the treatment condition
reported a significantly lower amount of external eating at the
post-measurement, t(11) = 2.52, p = .03, d = .60.
Emotional eating
A significant interaction effect was observed for the emotional
eating subscale, F(1, 24) = 8.15, p < .01, g2 = .25. At the post-
measurement, participants in the treatment condition reported
a significantly lower amount of emotional eating, t(11) = 1.08,
p = .03, d = .53, compared to the control group t(13) = 1.08, p = .30.
Body image concern
A significant interaction between condition and scores on the
BSQ was observed, F(1, 24) = 9.64, p < .01, g2 = .29. Within group
comparisons revealed that participants in the treatment group
showed significantly less body image concern at the post measure-
ment, t(11) = 3.93, p < .01, d = .68, compared to the control group,
t(13) = .09, p = .93.
850 H.J.E.M. Alberts et al. / Appetite 58 (2012) 847–851
Table 1
Means and standard deviations of scores on all of the dependent measures.
Measure Control group
Pre measurement
1 1
BMI 31.46 (5.37)
Mindfulness 2.93 (.55)
Restrained eating 2.71 (.74) 1
External eating 3.35 (.41)
Emotional eating 3.69 (.87)
Body image concern 2.63 (.84)
Dichotomous thinking 2.46 (.70)
Food cravings 3.60 (.97)
Note: Numbers represent mean scores on each of the measures. Standard deviations are given in parentheses. Means within a row with the same
superscript concern within group comparisons that differ significantly at p < .05.
Dichotomous thinking
Scores on the Dichotomous Thinking Scale interacted signifi-
cantly with condition, F(1, 24) = 7.09, p = .01, g2 = .24. After the
intervention period, participants in the treatment condition re-
ported significantly less dichotomous thinking, t(11) = 2.41,
p = .03, d = .82, compared to the control participants, t(13) = 1.13,
p = .28.
Food cravings
A significant interaction for scores on the G-FCQ-T was observed,
F(1, 24) = 9.49, p < .01, g2 = .29. Participants in the experimental
group reported a significant decline in food cravings after the inter-
vention, t(11) = 2.72, p = .02, d = .98, whereas no difference in food
craving was observed for the control group, t(13) = 1.09, p = .30.
Discussion
The present results provide support for the efficacy of a mind-
fulness-based intervention for problematic eating behavior. Indi-
viduals who participated in an 8-week MBCT-based eating
intervention reported significantly lower levels of food cravings,
dichotomous thinking, body dissatisfaction, emotional eating and
external eating after the intervention period, compared to a wait-
ing list control group. In addition, the intervention group showed
a significantly stronger increase in trait mindfulness than the con-
trol group. These findings suggest that increasing mindful aware-
ness of internal experiences and automatic patterns related to
eating, emotion regulation, and self-acceptance may help to reduce
problematic eating behavior.
The current findings are in line with previous studies demon-
strating the beneficial effects of mindfulness on (problematic) eat-
ing behaviour and provide support for the notion that higher levels
of mindfulness affect different components of disrupted eating
behavior. First, mindfulness practice has been suggested to help
individuals ‘‘connecting’’ with their inner experiences (such as
hunger), thereby attenuating the sensitivity to external or emo-
tional cues to eat (Kristeller & Wolever, 2011). Indeed, the results
show that both emotional and external eating diminished signifi-
cantly in the mindfulness group. On a cognitive level, mindfulness
has been proposed to reduce identification with thoughts about
food, body and shape, thereby interrupting dysfunctional thinking
patterns (Albers, 2011). In line with this, participants in the treat-
ment condition engaged in less dichotomous thinking and reported
less concern about body weight and shape after the intervention
period. Finally, mindfulness has been linked with self-regulatory
processes. Mindfulness involves willingness to stay in contact with
uncomfortable and/or negative experiences, but without reacting
upon them, thereby decreasing impulsivity (Fetterman, Robinson,
Ode, & Gordon, 2010). Consistent with previous findings (Alberts
Experimental group
Post measurement Pre measurement Post measurement
31.23 (5.54) 34.23 (6.73) 33.85 (6.56)
3.03 (.49) 3.01 (.31) 1 3.35 (.30) 1
2.84 (.71) 1 3.09 (.39) 1 3.30 (.49) 1
3.35 (.40) 3.32 (.49) 1 3.03 (.48) 1
3.78 (.72) 3.63 (.92) 1 3.19 (.70) 1
2.64 (.95) 3.08 (.20) 1 2.42 (.82) 1
2.53 (.20) 2.48 (.32) 1 2.10 (.57) 1
3.70 (.20) 3.73 (.61) 1 3.19 (.20) 1
et al., 2010) the present study revealed that food cravings reduced
significantly in the mindfulness group. This finding suggests that
mindfully dealing with food cravings ultimately reduced food crav-
ings, which can be regarded as successful self-regulation.
Interestingly, the findings revealed a significant decrease for the
MBCT group relative to the waiting-list control group on all mea-
sures except for restrained eating and weight. With regard to re-
strained eating behaviour, both the control and the treatment
group reported a significant increase. At this point, however, it is
impossible to gain insight into the exact nature of the observed in-
crease in restraint. Restrained eating can be a form of dieting which
is externally driven and may interfere with self-attunement. In
contrast, mindfulness is internally-driven and promotes self-
attunement. In line with this, the present intervention aimed to in-
crease awareness of physical sensations such as hunger, satiety,
craving and stress. This is likely to reduce eating in the absence
of hunger. Indeed, research has demonstrated that teaching people
how to recognize and respond appropriately to hunger results in
healthier body weights (Ciampolini & Bianchi, 2006; Ciampolini,
Lovell-Smith, & Sifone, 2010). In addition, dietary restraint has of-
ten been linked with negative self-evaluations and body dissatis-
faction. The observed decrease in body concern and dichotomous
thinking for the treatment group may suggest that the restraint
behaviour of this group is guided to lesser extent by negative
self-evaluations compared to the control group. However, no defi-
nite conclusions on this matter can be drawn.
A marginally significant reduction in weight was observed for
individuals in the mindfulness group and a significant reduction
for the control group. A possible explanation for the less pro-
nounced reduction in BMI of the intervention group is the focus
of the intervention. Instead of promoting weight loss, the present
intervention aimed to increase awareness of both physical and
psychological determinants of eating in the absence of hunger.
Increasing awareness involves changing automatic and habitual
patterns and is likely to be a gradual process which continues to
develop and impact (eating) behaviour and weight. Follow-up
measurement could have provided valuable insights in the long-
term effects of the intervention.
In sum, the present study was an exploratory attempt to ad-
dress the effect of mindfulness on problematic eating behaviour.
Although the current findings are consistent with previous re-
search on mindfulness and eating, some limitations remain. First,
we used a relatively small sample size. Second, the present inves-
tigation used questionnaires to measure changes in cognition.
Including measures that do not solely rely on self-reports, could
have provided stronger evidence. Finally, adding a standard treat-
ment group to the design would have provided information on the
effectiveness of the current intervention in relation to other inter-
ventions. By addressing these concerns, future research may help
to further unveil the impact of this relatively novel approach to dis-
rupted eating behavior.
 H.J.E.M. Alberts et al. / Appetite 58 (2012) 847–851 851

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